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Scapholunate Ligament Injury

SL interosseous ligament injury: instability spectrum to SLAC, scaphoid-shift and imaging, arthroscopic grading, and repair/capsulodesis/tenodesis by chronicity.

Overview

Scapholunate instability is a complex condition where pathophysiology is identified through history, physical examination, and imaging [2]. Despite evolving diagnostic and treatment options, the ideal management remains an unresolved problem characterized by inconsistent results and ongoing concerns regarding complications [3]. Strong level 1 or 2 evidence for managing scapholunate instability in the absence of arthritis is lacking, meaning published recommendations are largely experience-based [7]. Treatment paradigms range from nonoperative management to surgical techniques including ligament repair, reconstruction, and arthrodesis [2].

Acute intervention within 6 weeks is preferable to chronic intervention for scapholunate interosseous ligament injuries [4]. Direct bony fixation using a suture anchor is generally successful in restoring stability and has produced acceptable functional mid-term results [5]. Primary repairs using double-loaded suture anchors demonstrate significantly higher strength compared with single-loaded anchors or transosseous repairs [29]. Patients with acute or subacute symptomatic dissociation treated with arthroscopic ligament repair and dorsal capsulodesis using suture anchors achieved satisfactory results at a minimum of two years of follow-up [8].

Conversely, proximal row carpectomy is not recommended for dissociation without degenerative changes due to disappointing results compared to other treatments [11]. Radioscapholunate arthrodesis for scapholunate advanced collapse II arthritis is associated with a high re-operation rate and fails to preserve the midcarpal joint as expected [19]. While early reports suggest bone-tissue-bone grafts are important, the lack of long-term outcome measurements makes determining their appropriate use difficult [9]. New individualized options like osteochondral grafting combined with proximal row carpectomy or distal scaphoid resection offer less invasive alternatives for advanced collapse and scaphoid nonunion advanced collapse [28].

Anatomy & Pathophysiology

The scapholunate ligament complex comprises critical stabilizers that dictate treatment strategies for scapholunate dissociation [6]. Surgical intervention aims to arrest the degenerative cascade by restoring ligament continuity and normalizing carpal kinematics [12]. Bilateral scapholunate widening may stem from nontraumatic aetiology, potentially progressing to carpal instability and osteoarthritis with advancing age [10], though no absolute evidence confirms that such wide gaps inexorably lead to these outcomes [10].

Experimental sectioning of multiple ligaments in normal wrists generates scapholunate instability with average motion comparable to Geissler IV wrists [16]. In contrast, surgical treatments for scapholunate advanced collapse result in decreased wrist kinematic motion and functional performance relative to normal wrists [21]. While combined palmar and dorsal scapholunate ligament reconstruction appears to restore wrist kinematics, it fails to return the neutral position of the scaphoid and lunate to normal [22].

Four-dimensional computed tomography represents a promising, non-invasive, and affordable method to assess and quantify wrist kinematics by extending conventional CT with a temporal dimension [14]. Muscle loading induces specific rotational patterns: the scaphoid consistently rotates into flexion and supination when the flexor carpi radialis is loaded, whereas the triquetrum rotates in flexion and pronation under the same conditions [26]. Furthermore, each of the three repair techniques for scapholunate dissociation with dorsal intercalated segment instability exerts distinct effects on carpal posture and alignment [24].

Classification

Diagnostic Criteria: Scapholunate instability is identified through history, physical examination, and imaging [2]. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics [12].

Treatment Algorithm: A novel ligament-based treatment algorithm for scapholunate dissociation is proposed based on injury stage and arthritic changes [6]. A ligament-based treatment algorithm is proposed based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes [18]. Published recommendations for management of scapholunate instability in the absence of arthritis are largely experience-based [7]. Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking [7].

Acute vs. Chronic Management: Acute intervention (within 6 wk) is preferable to chronic intervention for scapholunate interosseous ligament injuries [4]. Patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor had satisfactory results at a minimum of two years of follow-up [8]. Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability [5]. Direct bony fixation of the ruptured scapholunate ligament using a suture anchor has produced acceptable functional mid-term results [5].

Graft and Reconstruction Options: Early reports indicate that the bone–tissue–bone (BTB) graft will be an important part of scapholunate dissociation treatment [9]. The lack of long-term outcome measurements for bone–tissue–bone (BTB) surgeries makes it difficult to determine the appropriate use of these treatment modalities [9].

Contraindications and Prognosis: Proximal row carpectomy (PRC) is not recommended for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [11]. The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [3].

Other Considerations: Bilateral scapholunate widening may have a nontraumatic aetiology [10]. Bilateral scapholunate widening may progress to carpal instability and osteoarthritis with advancing age [10]. There is no absolute evidence to confirm that bilateral wide gaps inexorably progress to carpal instability and osteoarthritis [10]. Sectioning multiple ligaments in normal wrists to create scapholunate instability causes average motion comparable to that seen in Geissler IV wrists [16].

Clinical Presentation

Scapholunate instability is identified through history, physical examination, and imaging [2]. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics [12]. Acute intervention within 6 weeks is preferable to chronic intervention for scapholunate interosseous ligament injuries [4]. Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability [5] and has produced acceptable functional mid-term results [5]. Patients with acute or subacute symptomatic dissociation who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results at a minimum of two years of follow-up [8]. Dorsal intercarpal ligament capsulodesis is a good option for treating early stages of scapholunate instability [27].

Diagnostic Imaging: Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics [14], extending conventional CT by incorporating the temporal dimension [14]. An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of scapholunate interosseous ligament tear had a sensitivity of 72% and a specificity of 100% [20]. Radiolunate arthritis can occur in association with scapholunate dissociation [17], and the generally held view that the radiolunate articulation is spared in scapholunate advanced collapse is not universally true [17].

Management Evidence and Prognosis: The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [3]. Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking [7], and published recommendations are largely experience-based [7]. No statistically significant or clinically relevant differences were found when comparing radiographic findings, patient rated outcomes and wrist motion following acute and subacute scapholunate ligament repair at a median follow-up of 5.5 and 6.1 years [13]. There is no absolute evidence to confirm that bilateral wide gaps inexorably progress to carpal instability and osteoarthritis [10]; however, patients without carpal instability or osteoarthritis were younger than those with bilateral scapholunate widening [10]. Proximal row carpectomy is not recommended for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [11].

Investigations

Plain radiography: Scapholunate instability is identified through history, physical examination, and imaging [2]. Bilateral scapholunate widening may have a nontraumatic aetiology [10]. While bilateral widening may progress to carpal instability and osteoarthritis with advancing age, there is no absolute evidence to confirm that bilateral wide gaps inexorably progress to carpal instability and osteoarthritis [10]. Radiolunate arthritis can occur in association with scapholunate dissociation, challenging the generally held view that the radiolunate articulation is spared in scapholunate advanced collapse [17]. Treatment algorithms for scapholunate dissociation should be based on injury stage and arthritic changes [6].

MRI: An MRI demonstration of dorsal subluxation of the scaphoid of as little as 10% as a predictor of scapholunate interosseous ligament (SLIL) tear had a sensitivity of 72% and a specificity of 100% [20].

CT: Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics [14]. 4DCT extends conventional CT by incorporating the temporal dimension [14]. Sectioning multiple ligaments in normal wrists to create scapholunate instability causes average motion comparable to that seen in Geissler IV wrists [16].

Other Considerations: Strong evidence (level 1 or 2) for the management of scapholunate instability in the absence of arthritis is lacking [7]. Published recommendations for scapholunate instability management are largely experience-based [7].

Treatment

Scientific and clinical evidence is applied to a treatment paradigm for scapholunate injury and modified based on emerging evidence [1]. Treatment options for scapholunate instability range from nonoperative management to surgical techniques including ligament repair, reconstruction, and arthrodesis [2]. The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [3]. Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics [12].

Non-Operative

Published recommendations for management of scapholunate instability in the absence of arthritis are largely experience-based [7]. Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking [7].

Operative

Indications: Acute intervention within 6 weeks is preferable to chronic intervention for scapholunate interosseous ligament injuries [4]. A novel ligament-based treatment algorithm for scapholunate dissociation is proposed based on injury stage and arthritic changes [6]. Proximal row carpectomy (PRC) is not recommended for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments [11].

Surgical Approach / Technique: Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability [5]. Patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor had satisfactory results at a minimum of two years of follow-up [8]. Early reports indicate that the bone–tissue–bone (BTB) graft will be an important part of scapholunate dissociation treatment [9]. The RASL reconstruction technique re-aligns the scaphoid and lunate, restores function, reduces pain, and appears to be robust over time [15].

Implant Selection: Direct bony fixation of the ruptured scapholunate ligament using a suture anchor has produced acceptable functional mid-term results [5]. The lack of long-term outcome measurements for bone–tissue–bone (BTB) surgeries makes it difficult to determine the appropriate use of these treatment modalities [9].

Other Considerations: There is no absolute evidence to confirm that bilateral wide gaps inexorably progress to carpal instability and osteoarthritis [10]. A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis for scapholunate advanced collapse II arthritis [19]. The expected benefit of preserving the midcarpal joint was not observed in patients receiving radioscapholunate arthrodesis for scapholunate advanced collapse II arthritis [19].

Complications

Instability: Despite evolving diagnostic and treatment options, the ideal management for scapholunate instability remains an unresolved problem characterized by inconsistent results [3]. Ongoing concerns regarding complications persist for this injury [3]. Bilateral scapholunate widening may progress to carpal instability and osteoarthritis with advancing age, though there is no absolute evidence confirming that bilateral wide gaps inexorably lead to these outcomes [10].

Arthritis: Radiolunate arthritis can occur in association with scapholunate dissociation, challenging the generally held view that the radiolunate articulation is spared in scapholunate advanced collapse [17].

Other Considerations: Direct bony fixation of the ruptured scapholunate ligament using a suture anchor has produced acceptable functional mid-term results for this difficult-to-treat injury [5]. However, the lack of long-term outcome measurements for bone–tissue–bone (BTB) surgeries makes it difficult to determine the appropriate use of these treatment modalities [9].

Recovery

Light activity (weeks): Evidence does not specify a precise week range for light activity or return to desk work; however, acute intervention within 6 weeks is preferable to chronic intervention [4].

Full activity (months): The evidence does not define a specific month range for full activity or return to sport. Direct bony fixation using a suture anchor is generally successful in restoring stability [5] and has produced acceptable functional mid-term results [5]. Patients with acute or subacute symptomatic dissociation undergoing arthroscopic repair and dorsal capsulodesis with suture anchors achieved satisfactory results at a minimum of two years [8].

Complete recovery / outcome plateau (months): No statistically significant or clinically relevant differences were found between acute and subacute repairs regarding radiographic findings, patient-rated outcomes, and wrist motion at median follow-ups of 5.5 and 6.1 years [13]. The RASL reconstruction technique appears robust over time, re-aligning the scaphoid and lunate to restore function and reduce pain [15]. While bone-tissue-bone (BTB) grafts show early promise, long-term outcome measurements are lacking to determine their appropriate use [9]. Bone-retinaculum-bone (BRB) autograft reconstruction is a potential long-term option for dynamic instability, though results may deteriorate over time [30].

Rehabilitation protocol: The ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications [3]. Strong evidence (level 1 or 2) for management in the absence of arthritis is lacking, and published recommendations are largely experience-based [7].

Functional milestones: Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics by extending conventional CT to incorporate the temporal dimension [14].

Key Evidence

  • [L5] The article demonstrates how scientific and clinical evidence is applied to a treatment paradigm for scapholunate injury and modified based on emerging evidence. (10.1016/j.jht.2016.03.010)
  • [Paper] This article reviews the pathophysiology of scapholunate instability, its identification through history, physical examination, and imaging, and the spectrum of treatment options ranging from nonoperative management to various surgical techniques including ligament repair, reconstruction, and arthrodesis. (10.1016/j.hcl.2009.08.006)
  • [L5] Despite the evolution of diagnostic and treatment options, the ideal treatment for scapholunate instability remains an unresolved problem with inconsistent results and ongoing concerns regarding complications. (10.1177/17531934221148009)
  • [L3] Acute intervention (within 6 wk) was preferable to chronic intervention for scapholunate interosseous ligament injuries. (10.1016/j.jhsa.2014.06.139)
  • [L4] Direct bony fixation of the ruptured scapholunate ligament using a suture anchor is generally successful in restoring scapholunate stability and has produced acceptable functional mid-term results for this difficult-to-treat injury. (10.1054/jhsb.1999.0340)
  • [L5] This review provides an update on the anatomy of the scapholunate ligament complex, the importance of critical ligament stabilizers, and pathoanatomy to inform treatment of scapholunate dissociation, proposing a novel ligament-based treatment algorithm based on injury stage and arthritic changes. (10.1016/j.jhsa.2023.05.013)
  • [L5] Strong evidence (level 1 or 2) for management of scapholunate instability in the absence of arthritis is lacking and published recommendations are largely experience-based. (10.1177/1753193412473861)
  • [L4] At a minimum of two years of follow-up, patients with acute or subacute symptomatic dissociation of scapholunate ligament instability who underwent arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor treatment had satisfactory results. (10.1186/s13018-023-04148-y)
  • [L4] The lack of long-term outcome measurements for these BTB surgeries makes it difficult for the hand surgeon to determine the appropriate use of these treatment modalities, but early reports have indicated that the BTB graft will be an important part of scapholunate dissociation treatment. (10.1016/j.jhsa.2006.11.011)
  • [L4] While bilateral SLAC wrists were not exceptional and patients without carpal instability or osteoarthritis were younger, there is no absolute evidence to confirm that bilateral wide gaps inexorably progress to carpal instability and osteoarthritis. (10.1177/1753193418819653)
  • [L4] The authors do not recommend PRC for the management of scapholunate dissociation in the absence of degenerative changes due to disappointing results compared to other treatments. (10.1177/1753193410382719)
  • [L5] Intervention for scapholunate instability is aimed at arresting the degenerative process by restoring ligament continuity and normalizing carpal kinematics. (10.1016/j.jhsa.2008.04.027)
  • [L3] At a median follow-up of 5.5 and 6.1 years, no statistically significant or clinically relevant differences were found when comparing radiographic findings, patient rated outcomes and wrist motion following acute and subacute SLL repair. (10.1016/j.jhsa.2015.06.055)
  • [L5] Four-dimensional computed tomography (4DCT) is a promising, non-invasive, and affordable method to assess and quantify wrist kinematics, extending conventional CT by incorporating the temporal dimension. (10.1177/17531934251326028)
  • [L4] It re-aligns the scaphoid and lunate, restores function, reduces pain and appears to be robust over time. (10.1016/s0363-5023(10)60091-3)
  • [L5] These findings support the hypothesis that sectioning multiple ligaments in normal wrists to create scapholunate instability causes average motion comparable to that seen in G4 wrists. (10.1016/j.jhsa.2020.12.015)
  • [L4] Radiolunate arthritis can occur in association with scapholunate dissociation, and the generally held view that the radiolunate articulation is spared in scapholunate advanced collapse is not universally true. (10.1016/j.jhsa.2010.04.008)
  • [L5] The authors propose a ligament-based treatment algorithm based on the stage of injury, degree and nature of ligament damage, and presence of arthritic changes to enable comparison of treatment and outcomes stratified by the stage of injury. (10.1016/j.jhsa.2023.06.016)
  • [L1] A high rate of re-operation was observed in patients receiving radioscapholunate arthrodesis, and the expected benefit of preserving the midcarpal joint was not observed. (10.1177/1753193418778471)
  • [L2] An MRI demonstration of dorsal subluxation of the scaphoid, of as little as 10%, as a predictor of SLIL tear had a sensitivity of 72% and a specificity of 100%. (10.1016/j.jhsa.2017.06.015)
  • [L2] Both surgical groups demonstrated decreased wrist kinematic motion and functional performance compared with individuals with normal wrists. (10.1016/j.jhsa.2015.04.035)
  • [L4] Combined palmar and dorsal SL ligament reconstruction seems to restore wrist kinematics, although the neutral position of the scaphoid and lunate are not restored to normal. (10.1016/j.jhsa.2024.11.014)
  • [L5] In this cadaveric model of scapholunate dissociation with dorsal intercalated segment instability and DST, each of the 3 repairs had different effects on carpal posture and alignment. (10.1016/j.jhsa.2021.05.030)
  • [L5] The scaphoid consistently rotated into flexion and supination when the FCR was loaded, while the triquetrum rotated in flexion and pronation. (10.1016/j.jhsa.2010.09.023)
  • [L4] Dorsal intercarpal ligament capsulodesis is a good option for treating early stages of scapholunate instability. (10.1177/1753193420911338)
  • [L4] New individualized options, like osteochondral grafting in combination with proximal row carpectomy or distal resection of the scaphoid, allow for less invasive but equally effective procedures. (10.1177/1753193420973322)
  • [L5] Primary scapholunate ligament repairs using double-loaded suture anchors demonstrated significantly higher strength compared with single-loaded anchors and transosseous repairs. (10.1016/j.jhsa.2015.03.031)
  • [L4] BRB autograft reconstruction has the potential to be a viable long-term treatment option for dynamic scapholunate instability, though results may deteriorate over time. (10.1016/s0363-5023(09)60082-4)

See Also

References

[1] Rehabilitation for scapholunate injury: Application of scientific and clinical evidence to practice. Journal of Hand Therapy. 2016. DOI: 10.1016/j.jht.2016.03.010

[2] The Diagnosis and Treatment of Scapholunate Instability. Hand Clinics. 2010. DOI: 10.1016/j.hcl.2009.08.006

[3] Scapholunate instability: why are the surgical outcomes still so far from ideal?. Journal of Hand Surgery (European Volume). 2023. DOI: 10.1177/17531934221148009

[4] Scapholunate Interosseous Ligament Injuries: A Retrospective Review of Treatment and Outcomes in 82 Wrists. The Journal of Hand Surgery. 2014. DOI: 10.1016/j.jhsa.2014.06.139

[5] Scapholunate Ligament Repair Using the Mitek™ Bone Anchor. Journal of Hand Surgery. 2000. DOI: 10.1054/jhsb.1999.0340

[6] Scapholunate Instability: Diagnosis and Management – Anatomy, Kinematics, and Clinical Assessment – Part I. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.05.013

[7] Assessment of scapholunate instability and review of evidence for management in the absence of arthritis. Journal of Hand Surgery (European Volume). 2013. DOI: 10.1177/1753193412473861

[8] Arthroscopic scapholunate ligament repair and dorsal capsulodesis with suture anchor in acute and subacute scapholunate dissociation. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04148-y

[9] Bone–Tissue–Bone Repairs for Scapholunate Dissociation. The Journal of Hand Surgery. 2007. DOI: 10.1016/j.jhsa.2006.11.011

[10] Bilateral scapholunate widening may have a nontraumatic aetiology and progress to carpal instability and osteoarthritis with advancing age. Journal of Hand Surgery (European Volume). 2019. DOI: 10.1177/1753193418819653

[11] Proximal row carpectomy for scapholunate dissociation. Journal of Hand Surgery (European Volume). 2010. DOI: 10.1177/1753193410382719

[12] Scapholunate Instability: Current Concepts in Diagnosis and Management. The Journal of Hand Surgery. 2008. DOI: 10.1016/j.jhsa.2008.04.027

[13] Outcomes of Acute versus Subacute Scapholunate Ligament Repair. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.06.055

[14] Dynamic wrist imaging: How it works and how to assess kinematic changes in wrists with scapholunate instability. Journal of Hand Surgery (European Volume). 2025. DOI: 10.1177/17531934251326028

[15] Reduction and Association of the Scaphoid and Lunate (RASL): Long-term Follow-up of a Reconstruction Technique for Chronic Scapholunate Dissociation. The Journal of Hand Surgery. 2010. DOI: 10.1016/s0363-5023(10)60091-3

[16] Carpal Motion in Chronic Geissler IV Scapholunate Interosseous Ligament Wrists. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2020.12.015

[17] Scapholunate Dissociation With Radiolunate Arthritis Without Radioscaphoid Arthritis. The Journal of Hand Surgery. 2010. DOI: 10.1016/j.jhsa.2010.04.008

[18] Scapholunate Instability: Diagnosis and Management – Classification and Treatment Considerations – Part 2. The Journal of Hand Surgery. 2023. DOI: 10.1016/j.jhsa.2023.06.016

[19] A blinded, randomized trial comparing bicolumnar arthrodesis to radioscapholunate arthrodesis in scapholunate advanced collapse II arthritis: a pilot study. Journal of Hand Surgery (European Volume). 2018. DOI: 10.1177/1753193418778471

[20] Dorsal Scaphoid Subluxation on Sagittal Magnetic Resonance Imaging as a Marker for Scapholunate Ligament Tear. The Journal of Hand Surgery. 2017. DOI: 10.1016/j.jhsa.2017.06.015

[21] Surgical Treatments for Scapholunate Advanced Collapse Wrist: Kinematics and Functional Performance. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.04.035

[22] Scapholunate Kinematics After Combined Palmar and Dorsal Ligament Reconstruction: A Quantitative Evaluation Using Four-Dimensional Computed Tomography. The Journal of Hand Surgery. 2025. DOI: 10.1016/j.jhsa.2024.11.014

[24] Comparative Analysis of 3 Techniques of Scapholunate Reconstruction for Dorsal Intercalated Segment Instability. The Journal of Hand Surgery. 2021. DOI: 10.1016/j.jhsa.2021.05.030

[26] The Role of the Flexor Carpi Radialis Muscle in Scapholunate Instability. The Journal of Hand Surgery. 2011. DOI: 10.1016/j.jhsa.2010.09.023

[27] Dorsal intercarpal ligament capsulodesis: a retrospective study of 120 patients according to types of chronic scapholunate instability. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420911338

[28] Management of scapholunate advanced collapse and scaphoid nonunion advanced collapse without proximal row carpectomy or four corner fusion. Journal of Hand Surgery (European Volume). 2020. DOI: 10.1177/1753193420973322

[29] Biomechanical Analysis of Scapholunate Ligament Repair Techniques. The Journal of Hand Surgery. 2015. DOI: 10.1016/j.jhsa.2015.03.031

[30] Long-Term Outcomes of Scapholunate Ligament Reconstruction with Bone-Retinaculum-Bone Autograft. The Journal of Hand Surgery. 2009. DOI: 10.1016/s0363-5023(09)60082-4

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4. Media and formats; technical modifications allowed. The Licensor authorizes You to exercise the Licensed Rights in all media and formats whether now known or hereafter created, and to make technical modifications necessary to do so. The Licensor waives and/or agrees not to assert any right or authority to forbid You from making technical modifications necessary to exercise the Licensed Rights, including technical modifications necessary to circumvent Effective Technological Measures. For purposes of this Public License, simply making modifications authorized by this Section 2(a) (4) never produces Adapted Material.

5. Downstream recipients.

a. Offer from the Licensor -- Licensed Material. Every recipient of the Licensed Material automatically receives an offer from the Licensor to exercise the Licensed Rights under the terms and conditions of this Public License.

b. No downstream restrictions. You may not offer or impose any additional or different terms or conditions on, or apply any Effective Technological Measures to, the Licensed Material if doing so restricts exercise of the Licensed Rights by any recipient of the Licensed Material.

6. No endorsement. Nothing in this Public License constitutes or may be construed as permission to assert or imply that You are, or that Your use of the Licensed Material is, connected with, or sponsored, endorsed, or granted official status by, the Licensor or others designated to receive attribution as provided in Section 3(a)(1)(A)(i).

b. Other rights.

1. Moral rights, such as the right of integrity, are not licensed under this Public License, nor are publicity, privacy, and/or other similar personality rights; however, to the extent possible, the Licensor waives and/or agrees not to assert any such rights held by the Licensor to the limited extent necessary to allow You to exercise the Licensed Rights, but not otherwise.

2. Patent and trademark rights are not licensed under this Public License.

3. To the extent possible, the Licensor waives any right to collect royalties from You for the exercise of the Licensed Rights, whether directly or through a collecting society under any voluntary or waivable statutory or compulsory licensing scheme. In all other cases the Licensor expressly reserves any right to collect such royalties, including when the Licensed Material is used other than for NonCommercial purposes.

Section 3 -- License Conditions.

Your exercise of the Licensed Rights is expressly made subject to the following conditions.

a. Attribution.

1. If You Share the Licensed Material (including in modified form), You must:

a. retain the following if it is supplied by the Licensor with the Licensed Material:

i. identification of the creator(s) of the Licensed Material and any others designated to receive attribution, in any reasonable manner requested by the Licensor (including by pseudonym if designated);

ii. a copyright notice;

iii. a notice that refers to this Public License;

iv. a notice that refers to the disclaimer of warranties;

v. a URI or hyperlink to the Licensed Material to the extent reasonably practicable;

b. indicate if You modified the Licensed Material and retain an indication of any previous modifications; and

c. indicate the Licensed Material is licensed under this Public License, and include the text of, or the URI or hyperlink to, this Public License.

2. You may satisfy the conditions in Section 3(a)(1) in any reasonable manner based on the medium, means, and context in which You Share the Licensed Material. For example, it may be reasonable to satisfy the conditions by providing a URI or hyperlink to a resource that includes the required information.

3. If requested by the Licensor, You must remove any of the information required by Section 3(a)(1)(A) to the extent reasonably practicable.

4. If You Share Adapted Material You produce, the Adapter's License You apply must not prevent recipients of the Adapted Material from complying with this Public License.

Section 4 -- Sui Generis Database Rights.

Where the Licensed Rights include Sui Generis Database Rights that apply to Your use of the Licensed Material:

a. for the avoidance of doubt, Section 2(a)(1) grants You the right to extract, reuse, reproduce, and Share all or a substantial portion of the contents of the database for NonCommercial purposes only;

b. if You include all or a substantial portion of the database contents in a database in which You have Sui Generis Database Rights, then the database in which You have Sui Generis Database Rights (but not its individual contents) is Adapted Material; and

c. You must comply with the conditions in Section 3(a) if You Share all or a substantial portion of the contents of the database.

For the avoidance of doubt, this Section 4 supplements and does not replace Your obligations under this Public License where the Licensed Rights include other Copyright and Similar Rights.

Section 5 -- Disclaimer of Warranties and Limitation of Liability.

a. UNLESS OTHERWISE SEPARATELY UNDERTAKEN BY THE LICENSOR, TO THE EXTENT POSSIBLE, THE LICENSOR OFFERS THE LICENSED MATERIAL AS-IS AND AS-AVAILABLE, AND MAKES NO REPRESENTATIONS OR WARRANTIES OF ANY KIND CONCERNING THE LICENSED MATERIAL, WHETHER EXPRESS, IMPLIED, STATUTORY, OR OTHER. THIS INCLUDES, WITHOUT LIMITATION, WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, NON-INFRINGEMENT, ABSENCE OF LATENT OR OTHER DEFECTS, ACCURACY, OR THE PRESENCE OR ABSENCE OF ERRORS, WHETHER OR NOT KNOWN OR DISCOVERABLE. WHERE DISCLAIMERS OF WARRANTIES ARE NOT ALLOWED IN FULL OR IN PART, THIS DISCLAIMER MAY NOT APPLY TO YOU.

b. TO THE EXTENT POSSIBLE, IN NO EVENT WILL THE LICENSOR BE LIABLE TO YOU ON ANY LEGAL THEORY (INCLUDING, WITHOUT LIMITATION, NEGLIGENCE) OR OTHERWISE FOR ANY DIRECT, SPECIAL, INDIRECT, INCIDENTAL, CONSEQUENTIAL, PUNITIVE, EXEMPLARY, OR OTHER LOSSES, COSTS, EXPENSES, OR DAMAGES ARISING OUT OF THIS PUBLIC LICENSE OR USE OF THE LICENSED MATERIAL, EVEN IF THE LICENSOR HAS BEEN ADVISED OF THE POSSIBILITY OF SUCH LOSSES, COSTS, EXPENSES, OR DAMAGES. WHERE A LIMITATION OF LIABILITY IS NOT ALLOWED IN FULL OR IN PART, THIS LIMITATION MAY NOT APPLY TO YOU.

c. The disclaimer of warranties and limitation of liability provided above shall be interpreted in a manner that, to the extent possible, most closely approximates an absolute disclaimer and waiver of all liability.

Section 6 -- Term and Termination.

a. This Public License applies for the term of the Copyright and Similar Rights licensed here. However, if You fail to comply with this Public License, then Your rights under this Public License terminate automatically.

b. Where Your right to use the Licensed Material has terminated under Section 6(a), it reinstates:

1. automatically as of the date the violation is cured, provided it is cured within 30 days of Your discovery of the violation; or

2. upon express reinstatement by the Licensor.

For the avoidance of doubt, this Section 6(b) does not affect any right the Licensor may have to seek remedies for Your violations of this Public License.

c. For the avoidance of doubt, the Licensor may also offer the Licensed Material under separate terms or conditions or stop distributing the Licensed Material at any time; however, doing so will not terminate this Public License.

d. Sections 1, 5, 6, 7, and 8 survive termination of this Public License.

Section 7 -- Other Terms and Conditions.

a. The Licensor shall not be bound by any additional or different terms or conditions communicated by You unless expressly agreed.

b. Any arrangements, understandings, or agreements regarding the Licensed Material not stated herein are separate from and independent of the terms and conditions of this Public License.

Section 8 -- Interpretation.

a. For the avoidance of doubt, this Public License does not, and shall not be interpreted to, reduce, limit, restrict, or impose conditions on any use of the Licensed Material that could lawfully be made without permission under this Public License.

b. To the extent possible, if any provision of this Public License is deemed unenforceable, it shall be automatically reformed to the minimum extent necessary to make it enforceable. If the provision cannot be reformed, it shall be severed from this Public License without affecting the enforceability of the remaining terms and conditions.

c. No term or condition of this Public License will be waived and no failure to comply consented to unless expressly agreed to by the Licensor.

d. Nothing in this Public License constitutes or may be interpreted as a limitation upon, or waiver of, any privileges and immunities that apply to the Licensor or You, including from the legal processes of any jurisdiction or authority.

Creative Commons is not a party to its public licenses. Notwithstanding, Creative Commons may elect to apply one of its public licenses to material it publishes and in those instances will be considered the “Licensor.” The text of the Creative Commons public licenses is dedicated to the public domain under the CC0 Public Domain Dedication. Except for the limited purpose of indicating that material is shared under a Creative Commons public license or as otherwise permitted by the Creative Commons policies published at creativecommons.org/policies, Creative Commons does not authorize the use of the trademark "Creative Commons" or any other trademark or logo of Creative Commons without its prior written consent including, without limitation, in connection with any unauthorized modifications to any of its public licenses or any other arrangements, understandings, or agreements concerning use of licensed material. For the avoidance of doubt, this paragraph does not form part of the public licenses.

Creative Commons may be contacted at creativecommons.org.